Project Summary Untreated tooth decay is the most common childhood chronic disease and is particularly acute among low-income children and adolescents, including those with Medicaid coverage. Lack of access to a dental provider, the high costs of care and lack of dental insurance coverage are the primary reasons why so many children do not obtain needed dental care. This proposed research will be the first to evaluate the causal impact of an innovative school-based program specifically tailored to address unmet dental needs among low-income children. This supply-side initiative enables dental hygienists employed by the Virginia Department of Health (VDH) to deliver preventive dental services to low-income children at ?high-need? schools under the remote supervision of a public health dentist. A hygienist practicing under ?remote supervision? has periodic communication with a public health dentist regarding patient care although the public health dentist has not performed an oral exam on the children screened and treated by the dental hygienist. The program was initially piloted during the 2009-2010 academic year in ?high-need? schools located in three health districts with high levels of unmet dental care needs and was expanded statewide in July 2012. We propose to analyze Medicaid enrollment and claims records (MAX data) spanning the years 2006 through 2016 to evaluate the causal impact of this highly innovative school-based dental care delivery model. We will use difference-in-differences analysis to compare receipt of preventive dental services among children who attend schools where a dental hygienist practices under remote supervision to receipt of preventive dental services among children who attend ?high-need? schools without this program. We will first evaluate the pilot program and then conduct a similar evaluation after the program was expanded and became available in additional health districts located throughout the state of Virginia. The rationale for evaluating both the pilot and expansion of this school-based initiative is twofold. First, the health districts selected to participate in the pilot program had very high levels of unmet dental care need and thus may yield a distorted picture of the true impact of the program. Second, an evaluation of a new program during its infancy may reflect implementation difficulties that are resolved over time. Thus, a comparison of the results from the pilot program and expansion of the program to additional health districts will address both of these concerns. Notably, the program itself represents a highly innovative solution to the dental care access crisis that exists among low-income children. Other policy solutions, such as increasing Medicaid reimbursement rates or the licensing of dental therapists?either have been found to be ineffective (Decker 2011; Buchmueller et al. 2015) or face intense opposition from practicing dentists (McElhaney 2014). Thus, our proposed evaluation will provide critical evidence and is likely to prompt other states to consider and enact similar legislation.